Healthcare Provider Details

I. General information

NPI: 1619965951
Provider Name (Legal Business Name): GLENDALE WEST DRUG CO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 S GLENDALE AVE
GLENDALE CA
91205-5657
US

IV. Provider business mailing address

1109 S GLENDALE AVE
GLENDALE CA
91205-5657
US

V. Phone/Fax

Practice location:
  • Phone: 818-548-5157
  • Fax: 818-548-1064
Mailing address:
  • Phone: 818-548-5157
  • Fax: 818-548-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY43706
License Number StateCA

VIII. Authorized Official

Name: MR. MALEK SET ALLAHDADAI
Title or Position: PRESIDENT
Credential:
Phone: 818-548-5157